The Patient with Peripheral Vascular Disease
A 71-year-old woman with a history of insulin dependent diabetes mellitus and severe peripheral vascular disease was admitted with gangrene of the left big toe. The patient had undergone surgery one month previously for debridement of the toe and adjoining area. There was no history of trauma to the toe but the patient reported multiple infections at the site and had been treated with parenteral antibiotics. For the past year, the patient had experienced pain in her left calf on walking. She had expressive aphasia secondary to a cerebral vascular accident 6 months ago. There was no specific history of cardiac disease; she had never been told of hypertension. She had smoked heavily in the past but had stopped about 2 years ago. She enjoyed an occasional drink. Except for occasional hydrodiuril and “heart tablets,” she did not regularly take any prescribed drugs apart from regular insulin (dosage range 12–40 units, adjusted according to the blood sugar level) and a 2-week course of oxacillin.
Physical examination was significant for lack of all distal pulses, blood pressure, 175/100 mmHg, temperature: 99.5°F. The patient was acutely distressed and complained of considerable pain in her foot.
Laboratory findings were as follows: hematocrit 27.7, hemoglobin 9.5 gm, white blood count 10,200/mm3, serum electrolytes-potassium 4.7 mEq/L sodium 139 mEq/l, chloride 101 mEq/L, blood glucose 316 mg/dl, BUN 48 mq/dl, creatinine 2.1 mg/dl. Urine: negative for acetone; 2+ glucose. Angiogram revealed occlusion of the left tibioperoneal trunk and the posterior tibial artery. Electrocardiogram showed normal sinus rhythm with evidence of an old subendocardial infarction. Chest x-ray showed bilateral basal congestion.
Peripheral vascular disease with occlusion of the major vessels below the knee was diagnosed and the patient was scheduled for left femoral popliteal bypass graft.
KeywordsChronic Obstructive Pulmonary Disease Peripheral Vascular Disease Significant Coronary Artery Disease Colloid Osmotic Pressure Cardiac Autonomic Neuropathy
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